Peer-Review ReportSubdural Drainage versus Subperiosteal Drainage in Burr-Hole Trepanation for Symptomatic Chronic Subdural Hematomas
Introduction
Symptomatic chronic subdural hematoma (scSDH) was first described by Virchow in 1857 as “pachymeningitis hemorrhagica interna” and is nowadays one of the most frequent diagnoses in neurosurgical practice (3, 5, 18). Its incidence is reported to be between 1.7 and 13.1 per 100,000 inhabitants per year (3, 5), and because scSDH is mainly found in elderly patients, there has been a steady, increasing incidence as the result of prolonged life expectancy in developing countries in recent years (1, 5). Therapeutic options include nonsurgical or surgical management by means of craniotomy, burr-hole trepanation, or twist drill craniostomy. In general, surgical treatment is recommended in case of neurological symptoms (1, 2, 5, 7, 9, 10, 11, 12, 13, 17, 19, 20). In those cases, double burr-hole trepanation is the surgical method of choice because studies showed the best outcome in patients treated with double burr-hole trepanation combined with irrigation and placement of a closed drainage system at first diagnosis of scSDH (8, 19). Furthermore, the authors of a recent prospective study showed that the use of a subdural drain (sdd) after burr-hole trepanation is safe and associated with reduced recurrence and mortality (14).
Nevertheless, up to now there are only few class (II) evidence and no class (I) evidence publications in the literature on the treatment of scSDH. Recent development in surgical treatment of scSDH includes a study of Zumofen et al. (20) in which they analyzed a closed subperiosteal drainage system (spd) instead of the commonly used sdd system. Remarkably, their results regarding outcome, complications, and postoperative symptoms were equal or superior to previously published studies (5). Moreover, a drainage system, which is not positioned in direct contact to cortical structures, bridging veins, or hematoma membranes, seems to prevent more likely postoperative seizures and severe complications (20). However, there is no comparative study that evaluates the advantages of the spd placement compared with sdd placement. In the present study, we compare for the first time the technique of spd with the more commonly used method of sdd in a single-center study by including the same surgeons and the same pre-, peri-, and postoperative management for both study groups.
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General Patient Data
In a retrospective study, we reviewed the data of 113 patients who underwent surgery for symptomatic chronic subdural hematomas from 2007 to 2009 at the Department of Neurosurgery, University Hospital Zurich. Inclusion criteria consisted of patients receiving double burr-hole trepanation, intraoperative irrigation, and placement of subdural or subperiosteal closed drainage system as the first surgical treatment. A total of 113 patients receiving surgery for 143 symptomatic chronic subdural
Study and General Patient Characteristics
One hundred thirteen patients underwent surgery for 143 scSDHs (Table 1). Forty-eight patients received treatment with spd for 21 left-sided, 20 right-sided, and 7 bilateral chronic subdural hematomas (cSDHs). Sixty-five patients received treatment with sdd for 14 left-sided, 28 right-sided, and 23 bilateral cSDHs. There were 32 male patients (66.7%) in the group treated with spd and 45 male patients (69.2%) in the group treated with sdd. The mean age was 77 years in the spd group and 71 years
Discussion
scSDH is one of the most frequent diagnosis in neurosurgical practice and is predominantly found in elderly patients (1, 3, 5, 18). Because life expectancy worldwide, especially in developing countries, has experienced a steady growth and because antiplatelet and anticoagulation therapy is widely available, the incidence of chronic subdural hematoma is becoming an even more frequent diagnosis (1, 3, 5, 18). The recommended treatment of scSDH is surgery with burr-hole trepanation, irrigation,
Conclusions
Our study shows for the first time a direct comparison of spd and sdd treatment in scSDH. Both methods have proven to be highly effective in the treatment of cSDH. General patient data, complications, outcomes, and mortality of both investigated study groups are comparable with or superior to previously published series. Because there is a clear tendency to less mortality and less serious complications and despite a slightly greater rate of hematoma remnant or recurrence, the treatment with
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Conflict of interest statement: The authors declare that this article was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Part of the content of this manuscript has been presented at the CNS Annual Meeting 2010 in San Francisco.